The State of Human Resources for Health in Zambia:Findings from the Public Expenditure Tracking and Quality of Service Delivery Survey, 2005/06

Oscar Picazo, Solomon Kagulura, and the PET/QSDS Team of MOH and University of Zambia (UNZA)Presentation prepared for the “Human Resources for Health Research Conference,” Mulungushi International Conference Center, Lusaka, Zambia, June 7-8, 2007

Disclaimer

This is part of a larger work on the Public Expenditure Review on the health sector in Zambia.

The report findings are unofficial, and do not reflect the views of the GRZ, the World Bank, or SIDA.

Comments received from this presentation will be incorporated in the finalization of the report.

MOH allocation to personnel expenditures Personnel expenditures in MOH budget (ZK billion) and share of

personnel expenditures to total MOH expenditures (%), 2002-2007

139.5 175.9 236.5 265.2 244.1 340.5

44 4340

46

39

50

0

50

100

150

200

250

300

350

400

2002 2003 2004 2005 2006 2007

0

10

20

30

40

50

60

PE in ZK Bn PE/MOH Exp (%)

Paradox of deepening HR crisis at a time of increasing flow of financing(Eriksson, 2006) Per capita health expenditures (US$) and share of personal emoluments to

health expenditures (%)

14

18

36

57

44

22

0

5

10

15

20

25

30

35

40

GRZ GRZ+Basket Funds GRZ+Basket+VerticalProj.

0

10

20

30

40

50

60

Introduction to the PET/QSDS Multistage sampling frame involving: provinces, districts, and

health facilities, and within them, health workers and patients Variety of instruments: specific questionnaires for health

facility, patient, health worker, DHMT

Provinces (No. of districts)

DHMTs Hospitals UHCs and RHCs

Total Facilities

Lusaka Province (3) 3 3 17 23

Copperbelt Province (4)

4 4 30 38

Southern Province (5)

5 5 25 35

Western Province (4) 4 3 28 35

Northern Province (5)

5 3 32 40

Total 21 18 132 171

Key findings

Staffing patterns and availability “Unaccounted” workers, staff absenteeism,

and tardiness Staff workload and morale Staff salary and benefits Salary management

A. Key findings on staffing patterns and availability Skewed staffing persists as reflected in the

composition of established posts Health facilities have very high rates of staff

vacancy The rate of staff turnover is worrisome,

especially in rural health clinics Health facilities are increasingly relying on

expatriate and volunteer staff

1: Skewed staffing pattern as reflected in composition of established posts% of estab’d posts

RHC UHC Hosp

ital

Clinical 63 62 62

Administrative

5 14 11

Other 31 24 28

RHCs have heaviest staffing for low-skill (other) posts

RHCs have highest proportion of clinical posts

Far more admin slots in UHCs compared to hospitals

2: High rates of staff vacancy, especially among clinical staff

53

54

56

57

58

59

60

66

66

74

79

0 50 100

Mpongwe

Namwala

Shangombo

Mpika

Chinsali

Kalomo

Nakonde

Kasama

Mufulira

Sesheka

Chilubi

33.5

19.6

23.4

43.4

37.7

53.4

53.2

0 20 40 60

Total

Other

Admin

Otherclinical

MW+nurses

COs+MLs

Doctors

3: High staff turnover especially in rural health centers

Staff Turnover RHC UHC Hospital All

Total staff 688 1,756 1,442 3,886

No. of staff who joined the facility this year

69 166 133 368

No. of staff who left the facility this year

148 172 60 380

Retired 15 20 7 42

Transferred 116 120 24 260

Resigned 10 22 14 46

Dismissed or suspended 7 10 15 32

4: Increasing reliance of hospitals on expatriate staff and HCs on volunteer staff% of Health Centers With

Volunteer Staff

32

48

0 20 40 60

RHCs

UHCs

% of Hospitals With Expatriate Staff

14

25

50

0 20 40 60

Otherexpatriate

staff

Expatriatenurse

Expatriatedoctor

B. Key findings on “unaccounted” workers, staff absenteeism, and tardiness The survey revealed inconsistency in the number of

posts actually filled A number of staff are posted in one facility but

working elsewhere Staff absenteeism is considerable; clinical staff have

the highest rates of absenteeism Staff-reported rate of absenteeism is much higher than the

rate found in the facility survey Tardiness is a much bigger problem than

absenteeism Absenteeism and tardiness erode in a major way

the actual availability of staff who are already in post

1: Inconsistency in the number of posts actually filled Total established posts: 5,038 Filled posts as a residual of vacant posts: 3,348 Filled posts reckoned from “staff count”: 3,885 Difference: 537 staff

More staff actually working than in the official payroll? Casual staff? Un-updated roster of established posts? Other reasons?

2: Some staff are posted in one facility but work elsewhere Number of staff

13

20

3

0

0

1

0

5

10

15

20

25

RHC UHC Hospital

Clinical Other

3: High rates of staff absenteeism, especially among clinical staff

9.6

1.4

4.2

14.1

13.8

20.1

31

0 10 20 30 40

Total staff

Other staff

Admin.staff

Otherclinical staff

MW+nurses

CO + ML

Doctors Composition of Absentees (%)

3.4

1.7

5.8

0.6

1.4

1

1.9

0.7

3.9

3.7

3.9

4.4

1

0.3

1.1

1.9

0 5 10 15

All

Hospital

UHC

RHC

Off. & unofficial leave

Outreach or sup'n

LT/ST training

Posted here, working elsewhere

Staff reported rate of absenteeism is much higher than the rate found in the facility survey Count of staff from facility

survey showed absenteeism rate of 9.6 percent

But health worker survey shows for the previous month: 30% of RHC staff were

absent (6 days/month) 16% of UHC staff were

absent (8 days/month) 16% of hospital staff were

absent (3 days/month) 21% of all staff were absent

(5 days/month)

Reasons for Absences (%)

40

189

33

Sick self

Sick relatives

Extra job to attend to

Others

4: Even higher rates of staff tardiness

Reasons for Tardiness (%)

35

1717

31

Longtravel time

Sickrelatives

"On-call"previousdayOthers

RHC UHC Hospital

All

% of staff tardy

37 47 47 43

Ave. no. of days/mo.

tardy

3 4 3 4

5: Absenteeism and tardiness erode actual availability of staffWorking days lost due to absenteeism per month

3,250

Working days lost due to tardiness per month

588

Total working days lost per month

4,108

Full-time equivalent (FTE) staff

187

187 FTEs are enough to staff: 2 hospitals @ 90

staff/hospital, or 4 UHCs @ 42

staff/UHC, or 21 RHCs @ 9

staff/RHC

C. Key findings on staff workload and morale Half of the staff complained of long hours worked,

because of the workload and their need to augment their meager incomes

Despite the reported long hours worked, the amount of time being spent by staff on direct patient care is being squeezed by other tasks

About half of the staff surveyed have low morale Health staff are engaged in various income-

augmenting economic activities, inside and outside the health facility

1: Staff perception of long hours worked (%)

52

59

52

53

47

41

48

47

0% 20% 40% 60% 80% 100%

All

Hospital

UHC

RHC

Too little

Just right

Too much

2: Amount of time spent on direct patient care Average no. of hours worked in a week by type of task, 2006

29.6

30.6

33

25.3

6.5

6.9

6

6.5

3.2

2.1

2.4

5.2

2.9

1.2

1.6

6

0 10 20 30 40 50

All

Hospitals

UHC

RHC

Patient careAdministrativeSocial mobilizationTrainingOthers

3: Low staff morale % of staff who are satisfied/dissatisfied

4

2

3

7

40

31

38

49

12

13

15

9

36

45

34

32

7

9

10

3

0% 20% 40% 60% 80% 100%

All

Hospitals

UHC

RHC

Highly satisfiedSatisfiedIndifferentDissatisfiedHighly dissatisfied

4. Income-augmenting activities of staff

5 18 11 39 29 10 9

3

9

6

05

1015202530354045

012345678910

% of staff

Ave. hours

D. Key findings on staff salary and benefits Salary levels of professional and clinical

workers are highly compressed, and a variety of allowances are being used to decompress overall payroll

The cash allowances and in-kind benefits are varied but highly fragmented, and cater only to a small proportion of staff

1: Problem of compressed salaries Composite monthly salaries and allowances (ZK million) of

clinical/professional health workers, 2005

0.981

1.142

1.142

1.142

1.142

1.142

1.683

2.43

2.688

3.072

3.778

0.255

0.285

0.355

0.355

0.355

0.355

0.892

0.97

0.973

1.049

2.456

0 1 2 3 4 5 6 7

Lab technician

Pharmacy technician

Lab technologist

Clinical officer

Midwife

Nurse

Sr. nurse

Tutor

Lab scientist

Pharmacist

Doctor

Salary Allowances

2: Highly-fragmented cash allowances…. The more generous allowances only cater to a small segment of the

workforce

247

89

213

256

97

225

182

57

121

171

0

50

100

150

200

250

300

Educ'l

Reten

'n s

chem

e

Transp

ort al

low

.

Top-ups

Food

Rural h

ardsh

ip

Oth

ers

Cloth

ing

On-c

all a

llow.

Housing

051015202530354045

Ave. amt. rec'd (ZK1,000) % of staff who received

… and in-kind benefits % of staff who received

0

10

20

30

40

50

60

70

80

90

E. Key findings on salary management Some staff experience problems of –

Delays in salaries Nonpayment of salaries Less-than-full salaries

A tenth of the staff reported paying “expediter’s fee” to obtain their salaries

1: Problem of delay in receipt of salaries

Percent of Staff RHC UHC Hospital All

% who received all salaries on time

28.7 16.7 19.8 21.9

% who experienced delays in receipt of salaries

71.3 83.1 80.2 78.1

Ave. no. of months delay 1 1 1 1

2: Problem of non-receipt of salaries

Percent of Staff RHC UHC Hospital All

% who received all salaries due the past 12 months

85.4 87.7 82.3 85.4

% who did not receive all salaries due the past 12 months

14.6 12.3 17.8 14.6

Ave. no. of months not paid 4 3 5 5

Reasons cited by staff for delay or nonpayment of salaries (%)

49

65

50

33

4

0

7

6

4

0

0

11

14

0

14

28

29

35

29

22

0 20 40 60 80

All

Hospital

UHC

RHCSystemic delay

Employer has nofunds

Salary withheld toservice outstandingdebts

Nonpayment notexplained

Other reasons

3: Problem of missing portion or unauthorized deduction of salariesPercent of Staff RHC UHC Hospital All

% who received all salaries net payable

90.9 86.0 75.0 84.5

% who received less than net payable salary, without consent or understanding

9.1 14.0 25.0 15.5

Ave. amount of salary

missing (ZK)

72,444 239,133 244,278 189,015

% who recovered missing portion of salary

18 0 25 21

4: Problem of paying “expediter’s fee” to obtain salariesPercent

of Staff

RHC UHC Hos

pital

All

% who paid ‘expe-diter’s fee’ to obtain salary

6 8 13 10

Percent of staff

RHC UHC Hospital

All

% who received salaries in cash

11 10 10 10

% who had salaries automatic-

ally deposited

in the bank

88 90 90 90

THANK YOU!